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By: Sage de Beixedon Breslin, Ph.D., & Tom Smith, Ph.D.
This article is a summation of “Transcultural health care practice: Transcultural clinical supervision in health care practice- Section three: Supervision in a multicultural context.” That article was originally copyrighted by Royal College of Nursing and is posted at https://www.rcn.org.uk/development/learning/transcultural/clinicalsupervision/sectionthree
Table Of Contents
The Professional Culture
Issues And Training For Cross-Cultural Practice
Perennial Problems
The Supervision Process
Culturally-aware supervision not only requires sensitivity within the supervisor/trainee relationship but must also take into consideration the general cultural context of the geographic location in which supervision takes place. In the original article posted by the Royal College of Nursing, the supervisory setting was located in “multiethnic Britain.”
While the internship matching process purportedly links interns with internship sites with closely matched desires and expectations, there is less of a guarantee for “matching” as interns graduate and move forward into supervisory relationships in post-doctoral experiences, as well as in post-licensure collaborations. We trust that supervisors will select trainees that are most appropriate for those supervisors to mentor, but that doesn’t mean that supervisor and supervisee will share everything in common. In fact, in the diverse spectrum of clinical life these days, chances are the individuals who constitute the supervisory dyad will have their own cultural and ethnic identities. Thus, not only will the relationships between clinician and client need to be culturally-aware and professionally sensitive, but the supervisory relationship, itself, will be an exercise in transcultural communication.
There are pros and cons to the discussion of multiculturalism. The proponents emphasize pluralism, whereas the opponents focus on the concept of discrimination. As noted in the original text, “To embrace the assumptions of pluralism is to affirm ‘the dominant culture benefits from coexistence and interaction with the cultures of adjunct groups’ (Axelson, 1985, p13).” From the pluralistic perspective, clinicians who are culturally-sensitive can honor and celebrate the viewpoints from ethnically-different groups. The perspectives of these groups are viewed as facilitating the evolution of the majority.
In the darker side of multiculturalism is the existence of discrimination, which is experienced in all multicultural societies. Whether in Britain, the US, or even in South Africa, people the world over recognize the differences amongst them and many do not celebrate the ways in which they are dissimilar. Certainly, in the helping professions, it is imperative that we value diversity and work to eliminate discrimination, but it is a task which requires persistence, compassion and courage.
Many clinicians are more accustomed to fighting discrimination than celebrating diversity. Unfortunately, this may actually promote the negative images and associations with minority membership. It is a real talent to balance recognition of diverse cultures with an authentic appreciation for the challenges that membership in those cultures present. We are not all created equal: while it would be terrific if it were true, it is not so in the current world climate. There are those that have power over others because of the color of their skin or due to their membership in a particular religion, political affiliation or economic group. As a result, we must acknowledge this reality and all that it requires of those groups involved. As clinicians, and as humans, we must both appreciate the differences that we have from one another, and recognize how we can learn and grow from relationship with one another, as well as observe and realize that differences can sometimes create overwhelming challenge and discrimination. When providing culturally-sensitive supervision, supervisors must seek opportunities for identifying and sharing these different perspectives but must also serve to protect those groups who may fall prey to prejudice and bias.
Even if one does not promote or accept pluralism, one cannot ignore differences. As noted in the original text,
“Allport (1958) postulated over thirty years ago that the mind is prone to categorise and to group in order to reduce the stress on the brain in its attempt to comprehend its surroundings. Therefore, there is a “normality of prejudgment” (p19). But this is not the problem. The problem, as Allport understood it and as we understand it, is that we become ‘partisan’. We start to attach “rightness”, or in our profession, normality, to the group of which we are members. In order to feel safe by virtue of group membership, we determine that other groups must be somehow defective.”
So, while we cannot necessarily change which people are members of the majority, we can change our approach and acceptance of those both within and outside of the majority. In order to promote pluralism, we must also engage all to protect all humans, and their inherent right to be different. If we are truly to coexist and to celebrate one another, we must lose the fear, and the often subsequent violence, associated with the unknown qualities of “the other.”
Definitions
In order to describe and label those who are different from ourselves, we must first describe and label ourselves. In order to define what is “different”, we must define the initial point of perspective, or what is “the same.”
Historically, the “majority position” in the British and US populations has been comprised of white males from European descent, or Caucasians. In large part, these white males have also held significant positions of power. Those described in the minority, then, were not only of different races but also did not occupy positions of power for the most part. Therefore, in both of these cultures, women could be described as minorities, while those in the affluent classes could not (they often held positions of power). Clear examples of this definition of “minority” exist in South Africa where brown-skinned residents pose the vast majority numerically, but hold very little power, and are thus considered “the minority”.
For decades, clinicians believed that the skills on which we were trained were techniques that could be used generically with all clients. This concept was best described by Smith (1981), who referred to it as the “myth of sameness.” This false belief denies the differences inherent in individual identity, group identity and even a wider universal identity, and can result in the development of stereotypes and prejudices. When a clinician is a member of the cultural majority, s/he may be even more likely to take an us/them approach to clients who are culturally different from them.
Group Training Exercise
In order to minimize the “us/them” approach, it is important that clinicians in supervision groups both analyze and define the ways in which they are both the same as one another and different from one another, especially regarding race, ethnicity, religion and cultural background. McGoldrick’s (1982) outline may provide a useful structure for asking the following questions of supervisees, whether during individual or group supervision:
Describe yourself ethnically
Who in your family experience influenced your sense of ethnic identity?
Which groups other than your own do you think you understand best?
Which characteristics of your ethnic group do you like most and which do you like least?
How do you think your own family would react to seeking the services of a helping professional?
While responses to the questions may be conservative at the outset of the discussion process, they are likely to become more complex as the discussion proceeds. Such discussion will not only identify the ethnic and cultural differences and similarities present, but will also uncover the covert biases, assumptions, and unconscious beliefs that are held in the group. By engaging trainees to address these issues, and the myth of sameness in their smaller supervision group, they are less likely to adhere to the myth with their minority clients. In addition to limiting the myth of sameness, this activity can allow supervisees to address cultural biases and ideas in a safe environment, so that they are less likely to make unwitting or culturally-insensitive comments towards clients from cultures that are different than their own.
Given that members of a single cultural group can represent a variety of characteristics of that group (along a continuum), it is likely that there will be diversity even within cultural groups that are represented in the supervision group itself. This may serve as a healthy reminder to clinicians that there are varying levels of acculturation and intra-group differences within cultural groups.
World Group
Understanding the “World Group” requires an understanding of one’s own world view and that of the “other” in order to relate at all (Ibrahim, 1985 and Sue, 1981). Understanding one’s own world view is not as easy as it may seem. Within the dominant cultural world view there are intra-group differences. For example, white males in San Francisco may have quite a different point of view than white males in Boise even though they hail from the same ethnic background. Put simply, there are many intra-group differences as well as obvious inter-group differences. It is easy to be seduced by assumptions regarding one’s own models of reality and that of others, particularly regarding structures of reasoning, ideas about human nature and relationships, time orientations (linear or cyclic for example), attitudes about work and leisure activities and other aspects of culture.
In pluralistic societies like the United Kingdom, the United States or even Brazil there is no real generic or inherent knowledge about culture. There are simply too many different people with intra- and inter-cultural differences. In this diverse situation to assume is anathema. One must ask questions, build the relationship and learn. This may be difficult for professionals who have a certain security (and perhaps arrogance) in what they think is adequate cultural knowledge. There must be a humble willingness to go into the unknown of another’s culture when “what worked in the past” is not an appropriate cultural fit. The professional must continually strive for cultural competence which is a result of life long learning.
An understanding of the “other’s” world view is central to identifying the presenting problem, developing a treatment plan and appropriate communication and counseling style. It is important to note that one does not necessarily understand the other’s world view simply by belonging to the same ethnicity or race. One may encounter a white man named Tom Smith not knowing that he was raised in a Spanish family with Mediterranean customs. Without that knowledge, the counselor may plunge headlong into a communication that is fraught with bigoted views and the therapeutic relationship does not even get off the ground (Mokuau, 1987).
It is, therefore, incumbent upon the professional to embrace sound cultural understanding all the while acknowledging the idiosyncratic differences within the culture and the individual. Understanding the assumptions of the majority culture is the first step. That understanding can identify the implicit and often unconscious assumptions that drive relationships. There is no doubt that it is difficult to understand one’s own culture or the majority culture because one is literally swimming in it and it is considered by the individual to be “normal”. But, alas, what is normal in one culture may not be normal and may be even offensive in another culture. It is all too easy to succumb to ethnocentrism.
Pederson (1987) listed 10 common assumptions of the helping professional in western cultures that block understanding, reinforce cultural biases and may inculcate bigotry:
The Professional Culture
Enmeshment in one’s own professional culture may preclude an adequate understanding of the client and their problems. Just look at the difficulty that the psychodynamic therapist has with the approach of the post-modern, narrative therapist. We must acknowledge that we have a particular professional stance and be open to changing our approach when needed. Professional egocentrism is a block to having many different psychotherapeutic tools in the “kit bag”. We can become institutionalized by our own biased approach to treatment.
This happens most often in the institutionalized health care systems. Think of nurses and how they are socialized by their professional culture to do things in a certain way (the “that’s the way we do thing around here” attitude). The professional culture socializes us in such a way that may be detrimental to the client or patient. An example of this occurs in the examining room: To ask a traditional Islamic woman to disrobe can be such a cultural disconnect that the patient may leave without treatment!
Monica McGoldrick (1982) suggested that we are continually taking “snapshots” of another’s culture much like we do when we are on vacation. The problem is we do not update our “photo album”. We categorize, take the picture and think that that is all there is to it. We over simplify and confuse the snapshot with the person in front of us. We confuse the map with the territory. Perhaps a more useful analogy would be that we should be constantly filming our interactions with the other culture so we have an accurate documentary.
Supervision Issues And Training For Cross-Cultural Practice
The health care professional can be best prepared by a culturally sensitive training program.
Christensen (1989) describes five stages that both minority and majority practitioners will experience as they develop a sophisticated cross-cultural awareness:
When one is “unaware”, no serious thought has ever been given to differences between human beings, be it cultural racial, ethnic, economic, sexual orientation and so on. The person identified with the majority culture is not even aware of their position of power and privilege and believes that it is the same for everyone and that they do not discriminate … the so-called “color-blind” people. The person in the minority culture is also not even aware that they are being discriminated against. They are in a state of denial.
It usually takes a precipitating event that “stops the world” so to speak where the individual in the majority culture find themselves either grossly discriminating against someone or those in the minority culture grossly discriminated against to be shocked into re-evaluating their world view regarding differences.
I recall going into a restaurant with a Latino friend of dark color and watched in amazement as everyone else was seated and waited upon and we were ignored. It is this kind of event that can begin the process of cross-cultural awareness and education.
In Stage two, the individual starts to see things s/he has not noticed before that brings a sense of discomfort and a feeling of “what’s wrong with this picture?”
The person in the majority culture begins to see the overt and covert discrimination that s/he now knows really exists. S/he becomes aware of his/her own participation in unjust discrimination and may want to distant him- or herself from it, but cannot.
The individual in the minority culture starts to see that s/he is in fact discriminated against. My Latino friend mentioned above did not even think anything was wrong (the situation was “normal” to him) until I pointed it out and then he got angry. He started to remember other incidences where he was treated less than a human being and realized, perhaps for the first time, that he belonged to a discriminated minority group … there were others like him.
In Stage two, both the majority and minority individuals may begin a dialogue or, at least, begin relating to each other with the objective of understanding each other.
In Stage three, beginning awareness evolves into conscious awareness of differences and how that impacts relationships and what that means.
The majority individual may begin to take personal responsibility for attitudes and behavior that was once denied. Feeling of guilt and anger may emerge. The minority individual begins to see more and more incidences of unfair discrimination and feelings of anger or powerlessness may emerge. They do not know what to do under the circumstances and may feel sad and rejected and thus, fall back into denial or surrender to the subjugating social attitudes.
Stage four brings a consolidation of awareness that results in a commitment to make changes and “value diversity” rather than see it as an impediment to building relationships.
The person in the majority culture makes a concerted effort to learn about those outside of his or her ken. The individual makes time to spend with those who are different from him/her and s/he may work to get others in the majority to see what is going on and begin a process of awareness. The individual in the minority culture may now begin to ask for redress of unfair attitudes or behavior and petition for acceptance into the majority culture. As in the majority culture, s/he may work on getting others to see that they are being discriminated against. S/he may start an organization or movement in extraordinary circumstances.
In this stage, the individuals in both the majority and minority begin to effectively work together in committed relationship for “humankind” rather than just holding allegiance to one’s particular group. WE all belong to the same species.
Finally, Stage five brings an awareness that goes beyond social imperatives regarding appropriate treatment of “those who are different” and is fully integrated into one’s world view. Such an awareness becomes a committed way of life and needs no longer to be sought out. A pluralistic society is realized and difference is valued as an asset to social and economic development.
These may be convenient stages to understand where one is on the road to cross-cultural enlightenment, but how does one get there? There are many opinions and methods. The following summarizes some of them:
Perennial Problems
Even the best of cross-cultural learning programs have deficiencies. No one program can solve social ills.
It is important to have the minority culture teach the majority culture. It does little to have a middle aged white man teach other middle aged white men about the culture of Black males.
Many training programs are not inclusive. Some limit themselves to the “Black/White” issue ignoring other ethnic groups or the disabled or those of different sexual orientations. Some ignore the differences within cultures. For example, most people do not know that there are over 32 distinct ethnic groups in China. Just to talk about the “Chinese” ignores these different groups. The same goes for Latin populations. The Mexicans are different than the Guatemalans who are different from the Columbians, Argentines or Chilenos and so on.
It is important to maintain humility after going through a training program. One does not learn everything in an afternoon. A person must always be on guard not to take a little knowledge and descend into stereotyping. Every person is different and cultural insights do not apply in all situations.
Finally, it is important to have a genuine and honest understanding that certain populations are clearly and intentionally marginalized. For example, it has been reported in November, 2007 that the income gap between Black and White males in the United States is widening. The politics of diversity can be brutal and those who have the power do not want to give it up.
The Supervision Process
By now, the reader probably understands that Cross-cultural supervision comes with a certain amount of anxiety and the potential for misunderstandings high. The supervisor must be sensitive to the minority intern and appropriately prepared to interact in a culturally congruent way to prevent or ameliorate any clash in values that may occur across cultural, ethnic or gender boundaries. In turn, the intern must also be prepared for the occasional misunderstanding and rather than becoming defensive, let the supervisor know how the interaction is lacking in a certain and particular understanding or sensitivity.
It is false to assume that racism and discrimination have been largely defeated in the developed industrialized world. It could easily be argued that it has in fact increased due to rancorous issues regarding immigration, economic fears and fears of terrorism. There is ample evidence of bigotry and discrimination in the health care system. Not too long ago in Los Angeles, California a Latino woman was left to die writhing in excruciating pain on the floor of an emergency room, totally ignored by nurses, doctors and other hospital staff. Would that have happened were she a well dressed Caucasian woman?
Such reprehensible and outrageous discrimination can also occur between hospital staff. Equal opportunities for advancement and training are sometimes out of reach for minority staff. Who gets what shifts can also become an acrimonious debate. Supervision under these circumstances can become adversarial and a danger to the client or patient who may receive uncaring or incompetent attention.
It is of paramount importance that any healthcare setting be trained in understanding and valuing diversity. This training should be ongoing and updated as necessary. The relationship between the supervisor and the intern is an evolving one of continuity and commitment to building the relationship especially when there are difficult misunderstandings or points of view. It is easy to slip back into dark, untoward thinking, limit communication and reject trust. The supervision process now breaks down and becomes irrelevant.
I recall supervising a young neophyte Black male therapist. When he would want to make a point he would get quite emotional in a way that I was not used to. It took me a little while to understand that this was his communication style that he learned growing up: As he told me: “If you don’t get a little heated up over your point then you are not really committed to it.” I finally understood; he was not getting defensive he was expressing his heartfelt commitment.
As the example above demonstrates there are numerous characteristics that can become the source of conflict. Ryan and Hendricks (1989) identified five of them: Cognitive orientation, motivational orientation, communication styles (the example above), value and sensory orientations.
In some cultures emphasis is placed on non-verbal emotional communication rather than cognitive analysis. You could talk the problem to death and still not get anywhere under the circumstance. What is considered to be relevant information changes from culture to culture (and maybe block to block in a large city).
What motivates people to seek help and what kind of help varies from culture to culture. Western European beliefs emphasize the power of the individual to change their circumstances. A person from another culture may be motivated by “unfulfilled spirits”, the need to accept the social or family imperative or status quo and have fatalistic attitude that does not consider the agency of personal power.
An example of conflict in communication style was given above.
Needless to say a difference in values orientation can be a source of great conflict and misunderstanding. In some cultures, to marry without explicit permission from parents would be unheard of; in Western culture the value is considered antiquated. In Western culture, questioning authority has been valued all the way back to Socrates. In other cultures, questioning a superior would be an egregious act requiring an apology.
Differences in sensory orientations are a little more difficult to understand. The West is a visual culture we are primarily oriented by what we see. In other cultures it is sound that is paramount. They want to hear the story not see it. Some culture put an emphasis on touching and other on NOT touching.
The danger that both the supervisor and the supervised must be constantly aware of is the human propensity for unconscious assumption and illusion. The supervisor cannot assume that his or her Nigerian intern has a privileged knowledge of everything Nigerian. The supervisor/intern relationship is one of power. The supervisor must be aware of this power and how it can either support and encourage the minority intern or repress them and undermine the effectiveness of the supervision. Subtle, implicit cultural assumptions about the minority “other” must be made explicit, confronted and resolved for the relationship to be an equitable one.
The relationship is dynamic and changes as the twists and turns of ethnic, racial or gender differences (and more) are negotiated. Both supervisor and intern must ask the question: What differences bring us together and what differences keep us apart? And, the question must be revisited time and again. The learning trajectory is for both the supervisor and intern. The supervisor particularly must be sensitive and have a thorough understanding of the racial, ethnic, gender, sexual orientation and family background of their intern or risk insult and the dissolution of the supervisory relationship.
Of course, to understand the differences of the intern the supervisor (of the majority culture) must examine their own race, gender, ethnicity and world view. The majority culture is usually very uncomfortable with this exploration as they take it for granted and they may fear that they will stumble upon some uncomfortable insights. A perennial example of this is the Causcasian male finally realizing that there is such a thing as white male privilege. They do not get pulled over for “driving while white” while there are many stories of African American males being pulled over for “driving while Black”.
Finally, we must not only be aware of ethnocentrism that posits that they way “my people” see it is the right way, but also cultural relativism that can lead to situational ethics and moral relativism. In some societies, honor killings are tolerated. However, humankind does not tolerate murder under any circumstance. Murder is evil and wrong.
In conclusion, to build effective supervisory relationships, differences of all kinds must be more than tolerated but, first acknowledged, recognized and understood. Then, the differences must be respected and valued and utilized. This does not mean that everyone is to be treated equally. We cannot treat everyone equally because we are all different. What we must to do is treat each person FAIRLY and as an individual with all their idiosyncratic ways. This is an ongoing evolving process. As the supervisor becomes more knowledgeable of self and their own ethnicity and culture, they will become more and more at ease in recognizing, understanding, valuing and utilizing the differences they encounter in their practice and supervision.